Ups and Downs, MACRA Modifiers, and E/M DGs in MPFS 2018 Proposed Rule

Tue, Jul 25, 2017

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EHR documentation

Part 3 of our proposed rule extravaganza is about the Medicare Physician Fee Schedule (MPFS) 2018 proposed rule. (Part 1 was QPP and Part 2 was OPPS). Let’s get down to business, checking out some highlights explained in recent issues of Medicare Compliance and Reimbursement.

Plusses and Minuses

The proposed 2018 conversion factor is 35.99, up 0.1 from the 2017 CF of about 35.89. CMS estimates the overall update to payments is +0.31 percent. That’s the 0.5 percent increase established under MACRA minus 0.19 percent for missing out on statutory misvalued code targets.

The estimated combined impact based on RVUs ranges from +3 percent for clinical social workers to -6 percent for diagnostic testing facilities, if the proposed MPFS goes through.

Keep in mind: The percentage the MPFS lists for your specialty may give you a rough idea, but it doesn’t mean that’s what you’ll actually experience. For example, as the American College of Cardiology stated in a summary, the expected decrease of 2 percent for cardiology is based on cardiology as a whole. Individual cardiologists may see a different percentage of change based on the services that cardiologist provides most.

Final tip: Hospitals with off-campus departments should carefully watch the proposed plan to reduce Medicare payments from 50 percent to 25 percent of the OPPS rate in 2018.

MACRA and Modifiers

MACRA and MIPS come up throughout the proposed rule. Coders may be particularly interested in the proposal to use modifiers to indicate patient relationships (more on that here). Under the proposed rule, clinicians may voluntarily report the modifiers starting Jan. 1, 2018. The voluntary reporting approach will allow time to get to know the modifiers and how to use them. The proposed modifiers are below:

  • X1 (Continuous/broad services)
  • X2 (Continuous/focused services)
  • X3 (Episodic/broad services)
  • X4 (Episodic/focused services)
  • X5 (Only as ordered by another clinician).

E/M News for H & E More Than M

You’ve had a long time to learn Medicare’s 1995 and 1997 E/M Documentation Guidelines, but there may be changes coming. Medicare proposes to review the guidelines, starting with the History and Exam components. The stated purpose of the revisions is to reduce administrative burden and bring the guidelines up to date. The challenge will be creating a set of guidelines that people can agree on and that work with current and emerging technology. The proposed rule states this is expected to take more than a year.

The AAFP posted its support for updating the Documentation Guidelines, noting they aren’t in line with today’s use of EHRs and team-based care.

What About You?

If you could overhaul the E/M documentation guidelines, what would be your top priority?

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4 Things to Watch From the OPPS 2018 Proposed Rule

Fri, Jul 21, 2017


outpatient hospital

We’re back for another installment of “what does 2018 (maybe) have in store”? We just covered the QPP proposed rule, and now we’ll take a look at the 2018 hospital outpatient prospective payment system (OPPS) proposed rule. CMS expects an overall 2 percent payment increase in 2018 (except for the changes mentioned in question 3 below). What has people talking?

1. Are Joint Replacements Moving to Outpatient?

The proposed rule takes total knee replacement off the inpatient-only list, opening the door to performing the procedure in a hospital outpatient setting. Experts note outpatient reimbursement could be roughly half the inpatient rate. Given the amounts at stake, your inpatient team should work carefully through how to support any procedures performed in the inpatient setting (and all that entails) using thorough documentation.

Watch for: CMS also asked for comments on allowing the knee replacements to be performed in ASCs and on allowing hip replacements in hospital outpatient and ASC settings.

2. Will Therapy Require Direct Supervision?

Years ago, CMS posted a clarification that hospital outpatient therapeutic services require direct physician supervision, but it wasn’t enforced for critical access hospitals (CAHs) and small rural hospitals. The most recent moratorium expired at the end of 2016, and the proposed rule reinstates non-enforcement for 2018 and 2019 for CAHs and small rural hospitals having 100 or fewer beds.

3. Will 340B Program Changes Go Through?

Currently Medicare pays the average sales price (ASP) plus 6 percent for drugs. The proposed rule indicates a change to 22.5 percent less than the ASP for drugs bought with a 340B program discount. (Vaccines would continue to follow current method.) The AHA’s post about the proposed rule showed that organization is firmly against this change and its potential impact on patients and the facilities that serve them.

4. Will DOS Policy Change for Labs to Bill Medicare Directly?

Current policy is that if a lab test is ordered less than 14 days after a patient’s discharge date, the hospital bills Medicare and then pays the lab, if the lab provided the test under arrangement. CMS is considering allowing labs to bill Medicare directly for molecular pathology tests and advanced diagnostic laboratory tests (ADLTs). The reason given is to help reduce operational burdens for hospitals and labs.

What About You?

What do you think about the proposed rule? Comments are being accepted until Sept. 11, 2017. Will you be commenting to CMS?


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Transition and Flexibility Are the Buzzwords for QPP 2018 Proposed Rule

Tue, Jul 18, 2017


flexibility in QPP 2018

CMS released the proposed 2018 Quality Payment Program (QPP) rule on June 20. To sum up the 1,000+ pages, 2018 will be something of a transition year like 2017 was for QPP, which was established under MACRA. If you read through the various summaries available, you’ll see the term “flexibility” used quite often, with specialty groups adding the warning that they need time to get through the complete rule before coming to a final verdict.

Here are some areas to watch:

  • Small provider exemption and low-volume threshold: The 2017 low-volume threshold was set at $30,000 in Medicare Part B allowed charges, or 100 or fewer Part B patients. The idea was to exclude practices from QPP requirements if they were under the low-volume threshold because the burden would be too great based on their numbers. In 2018, the proposed low-volume threshold is $90,000 or less in Part B allowed charges, or less than or equal to 200 Part B patients.
  • Virtual group reporting: If you’ve got 10 or fewer practitioners in your group (or if you’re solo), there’s a proposed option to let you join with others in that size-set to be scored as a group.
  • Hospital-based provider reporting at facility level: A proposed MIPS reporting option would let hospital-based clinicians use their facility’s value-based purchasing measure results.
  • EHR certified to 2014 Edition OK: MIPS-eligible clinicians can continue to use EHR technology certified to the 2014 Edition for 2018, but you’ll get a bonus under advancing care information (ACI) for using only 2015 Edition certified EHR. One reason for this proposal is a concern about the availability of certified products.
  • MIPS scoring for cost stays at 0%: The proposed weighting is 60% quality, 25% ACI, 15% improvement activities, 0% cost. But don’t ignore cost completely. The plan is still for cost to weigh in at 30% in 2019, so you need to be prepared to handle cost when it finally counts.

What Are Societies Saying?

Each specialty, setting, and industry has its own concerns. Here are some views from just a few groups:

  • AAPMR, the American Academy of Physical Medicine and Rehabilitation, declared a “win for physiatry” after seeing a proposed update to the 2018 measure Closing the Referral Loop: Receipt of Specialist Report. The update was in line with discussions AAPMR had with CMS about reporting difficulties.
  • ASCO, the American Society of Clinical Oncology, notes it will be analyzing a provision that could make some Part B drug payments subject to MIPS adjustments.
  • AHA, the American Hospital Association, posted a statement supporting proposals and encouraging a future focus on changes that provide an incremental approach to implementation and that promote alignment of hospital and clinician efforts.

CMS is accepting comments until Aug. 18, 2017, and you can get instructions on how to submit comments on page 1 of the proposed rule.

What About You?

Do you think the proposed rule adds flexibility? Do you think it achieves the goal of moving to a value-based approach?

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Learn the ABCs (and Zs) of IUD Coding

Fri, Jun 30, 2017



Intrauterine devices (IUDs) for birth control are fairly common, but somehow the coding for IUD-related services isn’t as clear-cut as it could be. In today’s post, get to know the codes and a common coding hurdle to watch for.

Go Through All the Code Sets to Find the Codes

CPT® provides these codes for IUD services:

  • 58300 (Insertion of intrauterine device (IUD))
  • 58301 (Removal of intrauterine device (IUD)).

ICD-10-CM offers codes specific to IUD encounters, too:

  • Z30.430 (Encounter for insertion of intrauterine contraceptive device)
  • Z30.431 (Encounter for routine checking of intrauterine contraceptive device)
  • Z30.432 (Encounter for removal of intrauterine contraceptive device)
  • Z30.433 (Encounter for removal and reinsertion of intrauterine contraceptive device).

ICD-10-CM does like to dig into the details, of course, so you’ll find other codes, too, like these complication codes:

  • T83.31XA (Breakdown [mechanical] of intrauterine contraceptive device, initial encounter)
  • T83.32XA (Displacement of intrauterine contraceptive device, initial encounter)
  • T83.39XA (Other mechanical complication of intrauterine contraceptive device, initial encounter).

HCPCS has a handful of options for you, too, including an S code that certain payers (other than Medicare) may accept for the supply of the IUD:

  • J7297 (Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg)
  • J7298 (Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg)
  • J7300 (Intrauterine copper contraceptive)
  • J7301 (Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg)
  • S4989 (Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies).

Watch for the Replacement Coding Roadblock

Comparing the CPT® codes to the ICD-10 codes reveals a hitch. ICD-10 makes it simple to report replacement using Z30.433 (removal and reinsertion). But CPT® has one code for removal (58301) and another for insertion (58300). So how do you report the CPT® codes during an encounter for replacement?

As long ago as April 1998, AMA’s CPT® Assistant said the removal of an IUD would be reported with one code and the insertion with another. That article may be old enough to vote by now, but it throws in a dose of reality that still holds true today: “Third-party payor reporting and reimbursement guidelines may vary.” And this is the issue coders have to deal with.

When you report both 58300 and 58301, many payers will pay you for only one of the codes, and often it’s the lower paying insertion code 58300 (2.06 nonfacility RVUs) instead of the higher paying removal code 58301 (2.69 nonfacility RVUs).

Experts advise getting your payers’ written policies to determine their view on correct coding. If no policy is available, watch to see which payers cover only one code when you report both. Then create an internal policy to be sure you’re coding all IUD replacement services consistently. For instance, you may choose to report only 58301 or even 58301-22 (Increased procedural services) to reflect the additional work of replacement.

For those payers that do accept both 58300 and 58301 for a replacement encounter, experts advise appending modifier 51 (Multiple procedures) to 58300 to identify the performance of multiple procedures at a single encounter (assuming the payer accepts modifier 51).

What About You?

How do you code IUD replacement? Do you code differently for different payers?

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Don’t Let EHR Tempt You to Upcode E/M Services

Tue, Jun 27, 2017


Don’t Let EHR Tempt You to Upcode E/M Services

EHRs can assist with many aspects of E/M coding (like tracking for coding based on time), but the problem of reporting higher-level E/M codes without medical necessity is still around.

A recent article in Ophthalmology Coding Alert discussed the example of a doctor who billed almost all level-four and level-five E/M codes for established patients. He followed the prompts of his EHR to fill in information, leading to detailed or comprehensive histories and exams even when the patient’s case didn’t require that level of service. Here’s why that’s a problem and how you can avoid it.

Steer Clear of Loophole Thinking

You assign established patient office/outpatient visit codes 99212-99215 based on meeting the requirements for two of three key components: history, examination, and medical decision making (MDM). This “two of three” wording has the unfortunate habit of leading coders and providers to thinking that as long as they check off the boxes for higher-level history and exams, they can report higher-level E/M codes like 99214 and 99215.

The problem is that this approach doesn’t take medical necessity into account for code choice.

Medicare states, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code” (Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.A). The manual goes on to state that billing a higher-level E/M when a lower-level E/M is warranted would not be medically necessary or appropriate, and the volume of documentation shouldn’t be the primary reason for your code choice.

In other words, meeting the exam and history requirements isn’t a loophole that lets you report higher-level (and therefore higher-paying) codes by ignoring medical necessity. (Why the focus on exam and history? MDM isn’t the same as medical necessity, but the nature of MDM — focused on the complexity of establishing diagnoses and selecting management options — can make the connection to medical necessity feel more direct. That’s why the exam/history combo tends to be more of a troublemaker for meeting medical necessity requirements.)

Ensure Both Providers and Coders Are in the Loop

Coding E/M services correctly requires a partnership between the coder and the provider because the provider is the one trained to determine medical necessity. The provider is the one who knows whether the patient’s individual case requires a higher-level exam and history. Coders know the coding rules and get to know their specialties well, but, in the end, determining and documenting medical necessity is the provider’s responsibility.

In clinical documentation improvement training, be sure providers and coders are both aware of medical necessity requirements and how to match documentation to the case. For instance, if your review finds the ophthalmologist is going into extensive detail on punctal plug patients’ genitourinary systems, it’s time for a discussion. Your coders may learn from the provider that there’s a clinical reason for an unexpected combo. Or the provider may reveal that the extensive documentation is the result of EHR prompts, leading you to decide it’s time to fine-tune your system, especially if the provider can’t exit the record without completing all the fields. In any case, you will have opened the conversation about what the documentation needs to include to define medical necessity and the appropriate E/M code level.

What About You?

What strategies have you found for ensuring your codes match medical necessity? What challenges have you faced?

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Don’t Get Too Comfortable With That Meaningful Use Payment – Here’s Why

Tue, Jun 20, 2017


MU overpayment news

When the title of an OIG report is about Medicare paying out hundreds of millions it shouldn’t have, that’s not great news for Medicare or the providers who got those funds. But that’s exactly what a report released June 12, 2017, says: “Medicare Paid Hundreds of Millions in Electronic Health Record Incentive Payments That Did Not Comply With Federal Requirements.”

Short version: From May 2011 to June 2014, the OIG estimates CMS paid about $729.4 million in EHR incentive payments to eligible professionals (EPs) who didn’t meet meaningful use requirements. A big part of the problem was that EPs didn’t maintain support for their attestations about meeting program requirements, and CMS didn’t do a lot of documentation reviews to catch this problem earlier, according to the OIG. OIG’s recommendations to CMS include attempting recovery of that $729.4 million.

Let’s dig in to the OIG recommendations and CMS’s responses a little more.

1. Get Back the Money From Improper Payments

Several of the OIG recommendations in the report are about recovering the money paid to providers who didn’t meet meaningful use requirements:

  • Recover $291,222 in payments made to EPs included in the OIG’s sample group who didn’t meet meaningful use requirements
  • Review incentive payments made during the audit period to attempt recovery of the estimated $729,424,395 in inappropriate incentive payments
  • Check a random sample of EP documentation from after the audit period to see if there were more inappropriate payments.

CMS agreed with the first point, but only partially concurred with the second two, claiming it already has implemented targeted risk-based audits to strengthen program integrity. The OIG report states those audits aren’t sufficient to catch the errors it found.

2. Educate EPs on Proper Documentation

Because finding appropriate support for attestations was such an issue in the review, the OIG made this recommendation:

  • Educate EPs on proper documentation requirements.

CMS concurred, agreeing to look into whether more education is needed, but pointed out they do have education available, including a fact sheet.

3. Get Back the Money From Overpayments

The OIG reviewed all payments to EPs who switched between the Medicare and Medicaid incentive payment programs and discovered overpayments, resulting in this recommendation:

  • Recover $2,344,680 in overpayments made to EPs who switched programs.

CMS agreed, asking the OIG to share the EPs’ information.

4. Use Edits to Ensure Switch Doesn’t Lead to Overpayments

To ensure providers don’t receive payment for both Medicare and Medicaid incentive programs when the EP switches, OIG had this recommendation:

  • Employ edits in the National Level Repository (NLR) system to guarantee providers who switch programs during the year get payment for only one EHR program.

CMS concurred, indicating it had already implemented the edits.

Bonus Recommendation: Keep Up the Safeguards for MACRA

One of the changes MACRA brings essentially moves the Medicare EHR incentive program into the Merit-Based Incentive Payment System (MIPS) as Advancing Care Information. So the OIG report includes a note that CMS has got to keep pushing to verify reporting of required measures.

What About You?

Do you participate? Have documentation tips to share?

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ICD-10-CM 2018 Posted! Let the Update Games Begin

Fri, Jun 16, 2017


2018 codes are coming

ICD-10-CM 2018 files are up on the CMS site! Here’s a quick overview of what’s coming when the new version goes into effect Oct. 1, 2017. (Looking for PCS? Click here.)

Check Changes by the Numbers

Based on the files posted, it looks like we’ll be dealing with more than 700 updates:

  • 360 additions
  • 142 deletions
  • 226 revisions
  • 71,704 codes total.

Single Our Your Specialty

Here are some changes from the chapters that will see the most updates. Be sure to check the complete files to see the details on the changes that will affect your specialty.

Eye and adnexa: Some of the changes in this section are as simple as a spelling correction (in H02.05-, entropian becomes entropion). But plenty of updates will have a real impact on your coding:

  • H44.2- (Degenerative myopia) will get new options to identify cases with choroidal neovascularization, macular hole, retinal detachment, foveoschisis, and other maculopathy by eye.
  • H54.- (Blindness and low vision) will see a lot of changes to allow you to identify the category for each eye, such as H54.1131 (Blindness right eye category 3, low vision left eye category 1).

Cardiology and vascular: There are four main areas to watch for these updates:

  • Myocardial infarction codes will expand, including a new specific option for type 2 (I21.A1).
  • Pulmonary hypertension options will increase under I27.2- to allow you to better define cause.
  • Heart failure coding options will grow with about 10 new changes, like I50.813 (Acute on chronic right heart failure) and I50.84 (End stage heart failure).
  • Cerebral infarction (I63.-), embolism and thrombosis (I82.81-), and varicose veins (I83.8-) will get some of those tough-to-spot changes, like revising plural terms to singular, so review those with care if you code them.

Gastroenterology: Coding for intestinal adhesions and obstruction will get more specific with about a dozen additions. To code correctly you’ll need to know whether obstructions are partial or complete.

Wound care: If you thought the non-pressure chronic ulcer code list couldn’t get any longer, think again! You’ll get lots of new options to help you report cases without evidence of necrosis.

Ob-gyn: If you code for women’s health, keep an eye on these changes:

  • You’ll be able to specify quadrant when coding for an unspecified lump in the breast under N63.
  • Tubal (O00.1-) and ovarian (O00.2-) pregnancy codes will expand to let you identify the side affected.
  • New subcategory O36.83- will allow you to report maternal care for abnormalities of the fetal heart rate or rhythm, specific to the trimester and fetus involved.
  • Antenatal screening encounter codes (Z36) will get a makeover with 17 new codes so you can identify what the screening is for, such as nuchal translucency (Z36.82) and Strep B (Z36.84).

Neuro: The list of changes for brain conditions is relatively long, but grasping the updates is pretty simple if you know the breakdown.

  • Injury codes of the optic tract (S04.03-) and visual cortex (S04.04-) will change terminology from “eye” to “side”
  • Expect a mass deletion of subsequent and sequela codes from S06.- that have the phrase “loss of consciousness of any duration with death.” (It makes sense when you think about it.)

Orthopedics: A few minor changes will lead to a whole lot of updates:

  • Code descriptors for metacarpal fracture (S62.3-) have a period in the middle in 2017, so the 2018 version changes that to a comma.
  • Phalanx fracture codes for the finger (S26.6-) and toe (S92.5-) will see a language swap from “medial phalanx” to “middle phalanx.”
  • Subluxation and dislocation codes (S63.12-) for thumb interphalangeal joints will get cleaned up to remove references to proximal and distal.

What About You?

How do you prep for ICD-10-CM updates? Tip: You can get automatic updates by signing up for ICD-10-CM Code Lookup FREE for a year!

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3 Things You Can Do Today to Prepare for a RAC Audit

Wed, Jun 7, 2017

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face audits by being prepared

What’s the first think you think of when you hear Recovery Audit Contractor? RACs have been around for a while (and not without controversy) as part of a Medicare program to find and correct past improper payments. Even folks who don’t get nervous at the thought of an audit probably don’t look forward to the extra work involved and the lengthy appeals process. There are some small steps you can take now to help make that mountain of an audit less intimidating.

1. Monitor Approved RAC Issues

If you haven’t checked your RAC’s approved issues in a while, it’s time to make a date with the contractor’s website. Some experts advise checking for new issues once a month or so.

Example: If you code for a physician in Performant Recovery’s region, you can go to the Approved Issues page and review the issues for your provider type, like payment for a global service along with payment for the service’s professional or technical component. RAC audits look at past claims, but you can still use the approved issue information to self-audit and to inform your training.

2. Pay Attention to LCDS and NCDs

Approved issues often relate to specific LCD and NCD requirements, so you’ll need to look beyond the approved issues page and delve into exactly what the policies say. (Which is just good coding, anyway, right?)

Example:Cotiviti lists Medical Necessity Sacral Neurostimulation as an approved issue. Reviewers check documentation to see whether the service meets coverage criteria, coding guidelines, and medical necessity requirements. The details section for the approved issue lists the specific NCD and LCD policies the review is based on, helping to direct you to the policies you need to know.

Bonus: The more you comply with Medicare rules, the lower your RAC work may be. Here’s why: The RAC program involves Additional Documentation Request (ADR) limits. For instance, a RAC can request only a certain percent of your paid claims in a specified period. The Statement of Work CMS published for RAC regions 1-4 states, “CMS will establish a method to adjust the ADR limits based on a provider’s compliance with Medicare rules.” If your denial rates are low, your ADR limit will be low. If your denial rates are high, then your ADR limit will be high, meaning the RAC can ask for a larger amount of information.

3. Create an Audit Team

Plan now so you don’t have to scramble to meet audit requests later.

For instance: Decide who will be responsible for alerting staff to deadlines, pulling records, and going through documentation before submission. Be sure team members know what they’ll be responsible for so they know what to expect. You also can identify experts from your team and from outside your organization to assist with an audit defense, if needed.

How About You?

Have you been through a RAC audit? What advice do you have for others?

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Step-by-Step Guide to Checking National Correct Coding Initiative Edits on SuperCoder

Tue, Jun 6, 2017


CCI Edits Checker is one of the tools SuperCoder subscribers use the most, so here’s a quick instructional guide to help users make the most of this resource, including the color-coded results and RVU options.
Note: This guide is specific to the CCI Edits Checker for Medicare PTP practitioner edits, but Outpatient Facility Coder subscribers will find that using our OPPS CCI Checker doesn’t vary too much from what you’ll find here.

Step 1: Access CCI Edits Checker

Once you’re logged into an account that includes tools, you can access CCI Edits Checker in several different ways. Start on the Coding Tools page, then choose the path that suits your needs.

1. Coding Tools page: Scroll down the page until you see the CCI Edits Checker widget.

2. Claims Edits page: Click Claims Edits in the top menu. A page with only Claims Edits widgets will open.

3. Dedicated page: Click Claims Edits/CCI Edits Checker in the left-side menu. This will open a new page titled National Correct Coding Initiative (NCCI or CCI) Edits. (Just for fun, which do you say? Medicare NCCI edits or CCI edits?)

Tip: On a code’s details or range page, choose the CCI Edits tab to see if the code is in the Column 1 position in any CCI edit pairs

Step 2: Choose Entry Method

CCI Edits Checker checks up to 25 codes at once. You can choose to enter codes in individual boxes (enter five characters and the cursor jumps automatically to the next box) or in a single box with the codes separated by commas. Click Make It Default, and you won’t have to repeat this step unless you want to change your preference.

Step 3: Choose Version/Date

The Version/Date box is set to the current CCI version based on date of service, but you can check any version going back to 2011.

Step 4: Choose Geographic Locality

Checker results include RVUs and fees for your codes. Select the applicable geographic location to see information specific to that area. Click Make It Default to check that area each time.

Step 5: Choose Setting

Select Non-Facility or Facility to see MPFS RVU/fee information for that setting. Again, you have the option of clicking Make It Default.

Step 6: Enter Codes

Pop in your codes, and click CCI Check.

Step 7: Review Results

The CCI Edits Checker lists your codes in simple descending RVU order based on MPFS data. Next to each code, you’ll see the descriptor and a color-coded alert identifying whether the code is in the Column 2 position in an edit with any of your other codes. Green means you’re in the clear, yellow means there’s an edit with modifier indicator 1 (so you can override with a modifier when appropriate), and red means there’s an edit with modifier indicator 0 (so overriding is never an option). You also get the rule behind the CCI edit.

Under the edit warning, you’ll find the code’s lay term and, depending on your subscription, links to articles. Check the right-side column for RVUs and fees.

Any Questions?

You get other goodies with CCI Edits Checker, too, like the option to download your results and easy access to the Medicare NCCI Policy Manual for NCCI guidelines. What else would you like to know?

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Take a Peek at 2018 ICD-10-PCS Updates

Thu, Jun 1, 2017


2018 updates

It’s only June of 2017, but for coders that means it’s time to start watching for 2018 updates. ICD-10-PCS files are already available for review. This inpatient coding system, which changes to the 2018 version on Oct. 1, 2017, will see 3,562 new codes and 646 deletions for a total of 78,705 codes in the next version. There will be 1,821 revisions, too. What’s changing? Here are some highlights.

Get Clued In to Code Set Changes

CMS helpfully offers an update summary. It pulls out three main changes to watch:

  • Revisions for clarity and usefulness in the Medical and Surgical section
  • Addition of endoscopic approaches to various tables
  • Guideline updates.

To view just the changes, download the Addendum from the CMS 2018 ICD-10-PCS and GEMs page.

Medical and Surgical: As you review the definitions addenda file, watch for deletions that have a related addition.

Example: For Section 0 (Medical and Surgical), Character 4 (Body Part), you’ll see “Delete” next to the ICD-10-PCS value Nose. But before you start wondering how you’ll report nose procedures, scroll down a bit to find the added value Nasal Mucosa and Soft Tissue. The terms in the definition for both values are the same.

Tables: The tables addenda file is more than 400 pages, so homing in on the changes specific to what you code will be important for manageable 2018 preparation.

Example: If you report procedures on the coronary arteries, check out the changes to the table for 3E0 with fourth character 7. You’ll see a new fifth character option 4 for Percutaneous Endoscopic.

Know What’s New for ICD-10-PCS Guidelines

The guideline changes you can expect to see came about in part from public comment. Something to keep in time next time you think of a suggestion!

Added: Totally Tubular New Guideline B4.1c

New guideline B4.1c (under B4, Body Part General Guidelines) clarifies coding procedures on tubular structures:

If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry.

Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part.

Revised: Completed Incomplete Procedure Guideline B3.3 

The wording for B3.3 will see some changes in the header and first sentence. The changes are in red:

Discontinued or incomplete procedures

If the intended procedure is discontinued or otherwise not completed, code the procedure to the root operation performed.

Revised: Root Operation Over Control Clarified in B3.7

Guideline B3.7 about Control will change the specified list of definitive root operations to a list of examples. The text involved in the changes is marked in red

2017: If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

2018: If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then the more definitive root operation is coded instead of Control.

Revised: Temporary Device at Center of B6.1a

Under Device General Guidelines, B6.1a will see an expansion, with the addition of all the red text

A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded. In limited root operations, the classification provides the qualifier values Temporary and Intraoperative, for specific procedures involving clinically significant devices, where the purpose of the device is to be utilized for a brief duration during the procedure or current inpatient stay.

How About You?

Have you reviewed the PCS files? What did you think of the changes?

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